Randomized clinical trial of glutamine-supplemented versus standard parenteral nutrition in infants with surgical gastrointestinal disease.

BACKGROUND: Addition of glutamine to parenteral nutrition in surgical infants remains controversial. The aim of this trial was to determine whether glutamine supplementation of parenteral nutrition in infants requiring surgery would reduce the time to full enteral feeding and/or decrease the incidence of sepsis and septicaemia. METHODS: A prospective double-blind multicentre randomized clinical trial was performed in surgical infants less than 3 months old who required parenteral nutrition. Patients were allocated to treatment or control groups by means of minimization. Infants received either 0·6 g per kg per day alanyl-glutamine (treatment group) or isonitrogenous isocaloric parenteral nutrition (control group) until full enteral feeding was achieved. Primary outcomes were time to full enteral feeding and incidence of sepsis. Cox regression analysis was used to compare time to full enteral feeding, and to calculate risk of sepsis/septicaemia. RESULTS: A total of 174 patients were randomized, of whom 164 completed the trial and were analysed (82 in each group). There was no difference in time to full enteral feeding or time to first enteral feeding between groups, and supplementation with glutamine had no effect on the overall incidence of sepsis or septicaemia. However, during total parenteral nutrition (before the first enteral feed), glutamine administration was associated with a significantly decreased risk of developing sepsis (hazard ratio 0·33, 95 per cent confidence interval 0·15 to 0·72; P = 0·005). CONCLUSION: Glutamine supplementation during parenteral nutrition did not reduce the incidence of sepsis in surgical infants with gastrointestinal disease. REGISTRATION NUMBER: ISRCTN83168963 (http://www.controlled-trials.com).

T cryptantigen activation is associated with advanced necrotizing enterocolitis.

BACKGROUND/PURPOSE: Thomsen-Friedenreich cryptantigen activation (TCA) exposes neonates with necrotizing enterocolitis NEC to the risk of hemolysis after transfusion of blood products. The authors aimed to determine the prevalence of TCA in neonates with NEC and to correlate TCA with severity of disease and outcome. METHODS: One hundred four neonates with NEC were tested for TCA on admission. Patients with TCA requiring transfusion were given packed red cells, low-titer anti-T fresh frozen plasma, and washed platelets to avoid hemolysis. RESULTS: Twenty-three infants had TCA, and 96% of these had stage III disease. The incidence of TCA was significantly higher in infants with stage III disease compared with those with stage II (30% v 4%; P <.01). A total of 91% of infants with TCA required laparotomy compared with 81% of those with no activation. At laparotomy, widespread disease was more common in the TCA group (71% v 55%). TCA did not significantly increase mortality rate (TCA, 39% v no TCA, 28%); this may reflect the transfusion policy of our unit. CONCLUSIONS: Twenty-two percent of neonates with NEC referred to our unit had TCA. There is an association between TCA and advanced NEC. Screening of neonates with advanced NEC for TCA is advised to identify those at risk of hematologic complications.

Noninvasive monitoring of nonshunted pulmonary capillary blood flow in the acute respiratory distress syndrome.

OBJECTIVE: Noninvasive monitoring of nonshunted pulmonary capillary blood flow, using the alveolar amplitude response technique (AART) in a porcine model of the acute respiratory distress syndrome. DESIGN: Experimental animal study. SETTING: University center for animal experiments. INTERVENTIONS: In 12 mechanically ventilated pigs, the nonshunted pulmonary capillary blood flow was varied by means of lung lavages and the application of positive end-expiratory pressure. MEASUREMENTS AND MAIN RESULTS: Nonshunted pulmonary capillary blood flow was determined by AART. Cardiac output (determined by the thermodilution method) corrected for venous admixture was used for comparison (r2 varied between .58 and .94; p < .01). The trend in the development of nonshunted pulmonary capillary blood flow as measured with AART was in agreement with the trend detected by cardiac output corrected for venous admixture in 92% of all events. CONCLUSIONS: We conclude that AART can be used to monitor changes in nonshunted pulmonary capillary blood flow in cases of acute respiratory distress syndrome noninvasively and continuously.

Delayed presentation of spilled gallstones.

The authors describe a case of a cutaneous sinus at the umbilical port site following spillage of gallstones during laparoscopic cholecystectomy. The sinus tract was explored using a flexible cystoscope, the stones found within were removed, and the tract itself was curetted. The consequences of spillage of gallstones and its prevention are discussed.

Results of adrenalectomy with various surgical approaches in the treatment of different diseases of the adrenal glands.

In a retrospective study, the impact of the various possible approaches for adrenalectomy were analyzed in 90 patients undergoing 120 adrenalectomies in one or two operations. The posterior approach proved to be the best tolerated procedure as expressed by the shortest operation time (less than 60 minutes) and the lowest blood loss (less than 100 milliliter). The number of opiate injections required was the lowest with this operation and the ambulation earliest (on the first postoperative day). Only two instances of wound infection, both from dorsal incision, occurred in operations for hypercortisolism in 46 patients (4 per cent). Splenectomy was necessary in four of 32 laparotomies (12 per cent), mostly for pheochromocytoma. There was no operative related mortality. The preoperative measures to reduce preoperative and postoperative complications are given.